Alcoholism
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Definition
Alcoholism or alcohol dependence is defined by the American Medical Association (AMA) as “a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.”
Description
Alcoholism is characterized by:
a prolonged period of frequent, heavy alcohol use.
the inability to control drinking once it has begun.
physical dependence manifested by withdrawal symptoms when the individual stops using alcohol.
tolerance, or the need to use more and more alcohol to achieve the same effects.
a variety of social and/or legal problems arising from alcohol use.
The effects of alcoholism are far reaching. Alcohol affects every body system, causing a wide range of health problems. Problems include poor nutrition, memory disorders, difficulty with balance and walking, liver disease (including cirrhosis and hepatitis), high blood pressure, muscle weakness (including the heart), heart rhythm disturbances, anemia, clotting disorders, decreased immunity to infections, gastrointestinal inflammation and irritation, acute and chronic problems with the pancreas, low blood sugar, high blood fat content, interference with reproductive fertility, increased risk of cancer of the liver, esophagus, and breast, weakened bones, sleep disturbances, anxiety, and depression. About 20% of adults admitted to the hospital (for any reason) are alcohol dependent. Men are more than twice as likely to be alcohol dependent than women, and smokers who are alcohol dependent are much more likely to develop serious or fatal health problems associated with alcoholism.
On a personal level, alcoholism, in many cases, leads to difficulties in marital and other relationships, domestic violence, child abuse or neglect, difficulty finding or keeping a job, impaired school or work performance, homelessness, and legal problems such as driving while intoxicated (DUI).
According to information derived from the United States National Longitudinal Alcohol Epidemiologic Study released in 2006, about 8% of American adults are dependent on alcohol (estimates range from 5-10%). About 34% of adult Americans do not use alcohol at all. Another 44% are occasional or non-dependent users. Alcohol is the third leading cause of preventable death in the United States (smoking and obesity rank first and second) and is responsible for about 85,000 deaths annually, about half from injury and half from disease. Alcoholism is involved in about 30% of homicides and 22% of suicides. It is the cause of about 20% of fatal motor vehicle accidents and is a contributing factor in between one-third and one-half of all vehicular accidents. Alcoholism costs the United States about $185 billion annually in costs related to violence, traffic accidents, lost work productivity, and direct medical expenses. The National Institute on Alcohol Abuse and Alcoholism estimates that at least 6.6 million children under age 18 live in households with at least one alcoholic parent and that before age 18 about 25% of children are exposed to family alcohol dependency or alcohol abuse.
Causes and symptoms
The risk of developing alcoholism has a definite genetic component. Studies have demonstrated that close relatives of people with alcoholism are more likely to become alcoholics themselves. This risk exists even for children adopted away from their biological families at birth and raised in a non-alcoholic adoptive family with no knowledge of their biological family’s alcohol use. However, no specific gene for alcoholism has been found, and environmental factors (e.g., stress) and social factors (e.g., peer behavior) are thought to play a role in whether a person becomes alcohol dependent.
Recently some researchers have suggested that there are two distinct types of alcoholism. According to these researchers, type 1 alcoholism develops in adulthood, often in the early twenties. It is most often associated with the desire to relieve stress and anxiety and is not associated with any criminal or antisocial behavior. Type 2 alcoholism develops earlier, usually during the teenage years. Drinking is done primarily to get high. Type 2 alcoholism is associated with violence, destructiveness, and other criminal and antisocial behavior. Those who study alcoholism do not universally accept the distinction between these two types of alcoholism. Research continues in this area.
The symptoms of alcoholism can be broken down into two major categories: symptoms of acute alcohol use and symptoms of long-term alcohol use.
Immediate (acute) effects of alcohol use
Alcohol exerts a depressive effect on the brain. The blood-brain barrier does not prevent alcohol from entering the brain, so the brain alcohol level will quickly become equivalent to the blood alcohol level. In the brain, alcohol interacts with various neurotransmitters to alter nerve function. Alcohol’s depressive effects result in difficulty walking, poor balance, slurring of speech, and generally poor coordination (accounting in part for the increased likelihood of injury). The affected person also may have impairment of peripheral vision. At higher alcohol levels, a person’s breathing and heart rates may be slowed and vomiting may occur (with a high risk of the vomit being breathed into the lungs, potentially resulting in aspiration pneumonia.) Still higher alcohol levels may result in coma and death.
Effects of long-term (chronic) alcoholism
Long-term use of alcohol affects virtually every organ system of the body:
Nervous system. An estimated 30-40% of all men in their teens and twenties have experienced alcoholic blackout from drinking a large quantity of alcohol. This results in the loss of memory of the time surrounding the episode of drinking. Alcohol also causes sleep disturbances, so sleep quality is diminished. Numbness and tingling (parethesia) may occur in the arms and legs. Wernicke’s syndrome and Korsakoff’s syndrome, which can occur together or separately, are due to the low thiamine (a B vitamin) levels found in many alcohol-dependent people. Wernicke’s syndrome results in disordered eye movements, very poor balance, and difficulty walking. Korsakoff’s syndrome affects memory and prevents new learning from taking place.
Gastrointestinal system. Alcohol causes loosening of the muscular ring that prevents the stomach’s contents from re-entering the esophagus. Acid from the stomach flows backward into the esophagus(acid reflux), burning those tissues, and causing pain and bleeding. Inflammation of the stomach also can result in ulcers, bleeding, pain, and a decreased desire to eat. A major cause of severe, uncontrollable bleeding (hemorrhage) in an people with alcoholism is the development of enlarged (dilated) blood vessels within the esophagus, which are called esophageal varices. These varices develop in response to liver disease, and are extremely prone to bursting and hemorrhaging. Hemorrhaging varices are often fatal. Diarrhea is a common symptom, due to alcohol’s effect on the pancreas. In addition, inflammation of the pancreas (pancreatitis) is a serious and painful problem in many people who abuse alcohol. Throughout the intestinal tract, alcohol interferes with the absorption of nutrients, which can result in a malnourished state. Alcohol is broken down (metabolized) in the liver and interferes with a number of important chemical reactions that occur in that organ. The liver begins to enlarge and fill with fat (fatty liver). Fibrous scar tissue interferes with the liver’s normal structure and function (cirrhosis), and the liver may become inflamed (hepatitis).
Blood. Alcohol may cause changes to all the types of blood cells. Red blood cells become abnormally large. White blood cells (important for fighting infections) decrease in number, resulting in a weakened immune system. This places alcohol-dependent individuals at increased risk for infections and may account in part for the increased risk of cancer faced by people with alcoholism. Platelets and blood clotting factors are affected, causing an increased risk of bleeding.
Heart. Small amounts of alcohol cause a drop in blood pressure, but with increased consumption, alcohol raises blood pressure into a dangerous range (hypertension). High levels of fats circulating in the bloodstream increase the risk of heart disease. Heavy drinking results in an increase in heart size, weakening of the heart muscle, abnormal heart rhythms, a risk of blood clots forming within the chambers of the heart, and a greatly increased risk of stroke due to a blood clot entering the circulatory system and blocking a brain blood vessel.
Reproductive system. Heavy drinking has a negative effect on fertility in both men and women. It decreases testicle and ovary size and interferes with both sperm and egg production.
Alcoholism during pregnancy
A large body of evidence indicates that maternal alcohol consumption during pregnancy contributes adversely to a fetus’s development. Abnormalities in infants and children associated with maternal alcohol consumption may include prenatal and postnatal physical retardation, neurological deficits (e.g., impaired attention control), mental retardation, behavioral problems (e.g., impulsivity), skull or brain malformations, and facial malformations (e.g., a thin upper lip and elongated flattened midface). These abnormalities, influenced by maternal alcohol consumption during pregnancy, are referred to as fetal alcohol effects (FAEs), or fetal alcohol syndrome (FAS) if a sufficient number of effects are apparent in the child.
FAS is the leading cause of mental retardation in the United States. One to two of every 1,000 infants born in the United States are afflicted with FAS. The incidence of FAS in children whose mothers drink heavily is 4% much higher than the rate in the general population. Research studies that have followed infants with FAS and FAEs across time have found that many of these children continue to have cognitive difficulties (e.g., lower IQ scores, more learning problems, poorer short-term memory functioning) and behavioral problems (e.g., high impulsivity, high activity level) into childhood and adolescence.
Diagnosis
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-T)R requires three of the following traits to be present for a diagnosis of alcohol dependence:
tolerance, meaning that a person becomes accustomed to consuming alcohol and must increase the amount in order to obtain the desired effect
withdrawal, meaning that a person experiences unpleasant physical and psychological symptoms when he or she does not drink alcohol
the tendency to drink more alcohol than one intends; being unable to avoid drinking or stop drinking once started
devoting large blocks of time to acquiring and consuming alcohol
unsuccessful attempts to reduce or stop alcohol use
choosing to use alcohol at the expense of other important tasks or activities such as work or family obligations
drinking despite evidence of negative effects on one’s physical and/or mental health
No laboratory tests exist that can screen for alcoholism with a high level of accuracy. Most alcoholism is diagnosed through patient and family history. However, alcoholism can be difficult to diagnose until late-stage physical symptoms become apparent because alcohol-dependent people often lie or about underestimate their alcohol use. In addition, many physicians do not routinely screen their patients using standardized questionnaires that may reveal alcohol problems.
Diagnosis is aided by administering specific psychological assessments that help to indicate what aspects of a person’s life may be affected by alcohol use. Determining the exact quantity of alcohol that a person drinks is less important than determining how drinking affects relationships, jobs, educational goals, and family life. Because the metabolism (how the body breaks down and processes) of alcohol varies among individuals, the quantity of alcohol consumed is not part of the criteria list for diagnosing either alcohol dependence or alcohol abuse.
One tool for initiating the diagnosis of alcoholism is the CAGE questionnaire. It consists of four questions, with the first letters of each key word spelling out the word CAGE. Answering yes two or more of these questions suggests an alcohol problem exists and should be addressed.
Have you ever tried to Cut down on your drinking?
Have you ever been Annoyed by anyone’s comments about your drinking?
Have you ever felt Guilty about your drinking?
Do you ever need an Eye-opener (a morning drink of alcohol) to start the day)?
Another longer questionnaire called the Alcohol Use Disorders Identification Test (AUDIT) is helpful in illuminating problems of alcohol abuse such as binge drinking that may be missed with the CAGE questionnaire.
Treatment
Treatment of alcoholism often is a combination of inpatient and outpatient therapy depending on the individual’s alcohol history and physical condition. The person with alcoholism often resists the idea that he or she has an alcohol problem and needs to stop drinking. Treatment cannot be forced on adults unless it is a condition imposed by a court of law. However, if the person is a danger to him- or herself or to others, immediate hospitalization may be possible without the individual’s consent.
The first step in the treatment of alcoholism, called detoxification, involves helping the person stop drinking and ridding his or her body of the harmful (toxic) effects of alcohol. Because the person’s brain and body has become accustomed to alcohol, the alcohol-dependent person will most likely develop withdrawal symptoms and need to be supported through them. Withdrawal will be different for different individuals, depending on the severity of the alcoholism as measured by the quantity of alcohol ingested daily and the length of time the patient has been alcohol dependent.
Withdrawal symptoms can range from mild to life threatening. Mild withdrawal symptoms include nausea, achiness, diarrhea, difficulty sleeping, sweatiness, anxiety, and trembling. This phase usually lasts no more than three to five days. More severe effects of withdrawal can include hallucinations in which a patient sees, hears, or feels something that is not actually present, seizures, an unbearable craving for more alcohol, confusion, fever, fast heart rate (tachycardia), high blood pressure (hypertension), and delirium (a fluctuating level of consciousness). Patients at highest risk for the most severe symptoms of withdrawal are those with other medical problems, including malnutrition, liver disease, or Wernicke’s syndrome. Severe withdrawal symptoms usually begin about three days after the individual’s last drink, and may last a variable number of days.
People going through mild withdrawal are monitored to make sure that more severe symptoms do not develop. Medications usually are unnecessary. Treatment of a patient suffering more severe effects of withdrawal may require sedative medications to relieve the discomfort of withdrawal and to avoid the potentially life-threatening complications of high blood pressure, fast heart rate, and seizures. Benzodiazepine drugs may be helpful in those patients experiencing hallucinations. If the patient vomits for an extended period, fluids may need to be given through a vein (intravenously, IV). Thiamine (a vitamin) is often included in the fluids, because thiamine levels are often very low in alcohol-dependent patients, and deficiency of thiamine is responsible for the Wernicke-Korsakoff syndrome.
After the individual is no longer drinking and has passed through withdrawal, the next steps involve helping the individual avoid relapsing and a return to drinking. This phase of treatment is referred to as rehabilitation. It can continue for a lifetime. Many programs incorporate the family into rehabilitation therapy, because the family has likely been severely affected by the patient’s drinking. Some therapists believe that family members, in an effort to deal with their loved one’s drinking problem, develop patterns of behavior that unintentionally support or enable the patient’s drinking. This situation is referred to as co-dependence. These patterns should addressed in order to help successfully treat a person’s alcoholism.
Sessions led by peers, in which recovering alcoholics meet regularly and provide support for each other’s recoveries, are considered among the best methods of preventing a return to drinking. The best-known group following this model is Alcoholics Anonymous (AA), which uses a 12-step program and a buddy (sponsor) system to help people avoid drinking. The AA steps involve recognizing the destructive power that alcohol has held over the individual’s life, looking to a higher power for help in overcoming the problem, reflecting on the ways in which the use of alcohol has hurt others and, if possible, making amends to those people. According to the American Psychological Association (APA), anyone, regardless of his or her religious beliefs or lack of religious beliefs, can benefit from participation in 12-step programs such as AA. The number of visits to 12-step self-help groups exceeds the number of visits to all mental health professionals combined.
Medications also are available that may help a recovering alcoholic avoid returning to drinking. These have been used with variable success; different medications may be more or less successful for different individuals. Disulfiram (Antabuse) is a drug which, when mixed with alcohol, causes unpleasant reactions including nausea, vomiting, diarrhea, and trembling. It was estimated that in 2008, 200,000 recovering alcoholics in the United States were taking disulfiram. Naltrexone (Depade, ReVia) helps to reduce the brain’s craving for alcohol. Acamprosate (Campral) works by reducing anxiety and insomnia that often occur when habitual drinkers become abstinent. Drugs alone will not prevent relapse. They are most effective when used in conjunction with a self-help program and/or psychotherapy aimed at changing behavior.
Alternative treatment
Alternative treatments may be a helpful adjunct for the recovering alcoholic once the medical danger of withdrawal has passed. Stress is a drinking trigger for many people. Alternative therapies can help the recovering alcoholic eliminate or manage stress. These therapies include massage, meditation, hypnotherapy, yoga, and acupuncture.
Malnutrition caused by long-term alcohol use may be addressed by nutrition-oriented practitioners with careful attention to a healthy diet and the use of nutritional supplements such as vitamins A, B complex, and C, as well as certain fatty acids, amino acids, zinc, magnesium, and selenium.
Herbal treatments include milk thistle (Silybum marianum), which is thought to protect the liver against damage. Other herbs are thought to be helpful for the patient suffering through withdrawal. Some of these include lavender (Lavandula officinalis), skullcap (Scutellaria lateriflora), chamomile (Matricaria recutita), peppermint (Mentha piperita) yarrow (Achillea millefolium), and valerian (Valeriana officinalis).
Prognosis
Recovery from alcoholism is a life-long process. The potential for relapse remains present and must be acknowledged and respected. Many individuals stop drinking and then relapse multiple times before attaining extended periods of sobriety. Statistics suggest that, among middle-class alcohol-dependent individuals in stable financial and family situations who have undergone treatment, 60% or more successfully stop drinking for at least one year.
Prevention
Prevention must begin at a young age since the first instance of intoxication usually occurs during the teenage years. It is particularly important that teenagers who are at high risk for alcoholism-those with a family history of alcoholism, early or frequent use of alcohol, a tendency to drink to drunkenness, alcohol use that interferes with school work, a poor family environment, or a history of domestic violence -receive education about alcohol and its long-term effects. How this is best achieved, without alienating these young people and thus losing their attention, is the subject of continuing debate and study.
Key Terms
Blood-brain barrier
A network of blood vessels characterized by closely spaced cells that prevents many potentially toxic substances from penetrating the blood vessel walls to enter the brain. Alcohol is able to cross this barrier.
Detoxification
The phase of treatment during which a patient stops drinking and is monitored and cared for while he or she experiences withdrawal from alcohol.
Neurotransmitter
One of a group of chemicals secreted by a nerve cell (neuron) to carry a chemical message to another nerve cell, often as a way of transmitting a nerve impulse. Examples of neurotransmitters include acetylcholine, dopamine, serotonin, and norepinephrine.
Relapse
A return to a disease state, after recovery appeared to be occurring. In alcoholism, relapse refers to a patient beginning to drink alcohol again after a period of avoiding alcohol.
Tolerance
A phenomenon during which a drinker becomes physically accustomed to a particular quantity of alcohol, and requires ever-increasing quantities in order to obtain the same effects.
Withdrawal
Those signs and symptoms experienced by a person who has become physically dependent on a drug, experienced upon decreasing the drug’s dosage or discontinuing its use.
For Your Information
Resources
Websites
“Alcoholism.” MedlinePlus. [cited January 14, 2009]. http://www.nlm.nih.gov/medlineplus/alcoholism.html.
“Alcohol Abuse and Alcoholism.” MedicineNet.com. February 20, 2008 [cited January 14, 2009]. http://www.medicinenet.com/alcohol_abuse_and_alcoholism/article.htm.
Thompson, Warren and R. Gregory Lande. “Alcoholism.” eMedicine.com. August 19, 2008 [cited January 14, 2009]. http://emedicine.medscape.com/article/285913-overview.
Organizations
Al-Anon/Alteen. 1600 Corporate Landing Parkway Virginia Beach, VA 23454-5617. Telephone:(757) 563-1600. Fax: (757) 563-1655 http://www.al-anon.alateen.org.
Alcoholics Anonymous. P.O. Box 459, New York, NY 10163. Telephone: (212) 870-3400. http://www.aa.org.
National Council on Alcohol and Drug Dependence. 244 East 58th Street 4th Floor New York, NY 10022. Telephone: (212) 269-7797. Fax: (212) 269- 7510. Help line: (800) NCA-CALL. http://www.ncadd.org.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). 5635 Fishers Lane, MSC 9304 Bethesda, MD 20892-9304. Telephone: (301) 443-3860. http://www.niaaa.nih.gov.
Other
“Online AA Recovery Resources.” Recovery, Inc. April 26, 2007 [cited January 14, 2009]. http://www.recovery.org/aa.
Alcoholism
Alcoholism treatment
Detoxification (Substance abuse treatment)
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